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How stakeholders can prepare now for unwinding of Medicaid public health emergency continuous eligibility

HMA Principal Jane Longo, Federal Policy Principal Andrea Maresca, and a team of experts from across HMA and HMA companies weigh in on the recent guidance to states on preparing for the end of the Public Health Emergency.

This year, one of the most significant issues the U.S. Department of Health and Human Services (HHS) is considering is whether and when to end the COVID-19 public health emergency (PHE) declaration. The PHE declaration has important implications for Medicaid enrollees as well as state Medicaid agencies and stakeholders.

In 2020, the Families First Coronavirus Response Act (FFCRA) offered states federal Medicaid funding at a higher match rate during the PHE if they met certain requirements, including freezing Medicaid eligibility standards, and maintaining continuous coverage for individuals enrolled in Medicaid.[i] The higher federal funding and related requirements are effective during the COVID-19 PHE period. However, once the PHE period ends, states will resume normal eligibility renewal reviews and must prepare for the end of enhanced federal funding. 

Medicaid enrollment grew by 13.6 million (19.1 percent) between the start of the COVID-19 pandemic in February 2020 and September 2021.[ii] Analysis conducted by HMA finds that roughly half of the Medicaid growth since the start of the COVID-19 emergency is due to provision of continuous coverage to individuals enrolled in Medicaid during the PHE. [iii]  Separately, the Urban Institute projects that as many as 15 million people could lose coverage in 2022 when the PHE and continuous eligibility end.[iv] 

The current COVID-19 PHE declaration expires April 16th and another extension is likely. While HHS has committed to giving states at least 60 days advance notice before terminating or letting the PHE declaration expire, states and the Centers for Medicare & Medicaid Services (CMS) are already immersed in planning for resumption of full renewals.

The sheer volume of Medicaid enrollment growth due to temporary COVID policies, the complexity of eligibility renewals, and the risk that large numbers of eligible individuals could lose coverage will require an all-hands on deck approach for states, managed care organizations (MCOs), providers, and other stakeholders.

In addition to a series of resources published in 2021 and 2022, CMS continues to regularly engage state Medicaid agencies and stakeholders to build out their plan for resuming normal operations to address pending applications, verifications, renewals, to improve the overall eligibility determination process going forward, and to implement strategies to minimize loss of coverage by eligible individuals.[v] The federal resources provide clarity on options and strategies available to states, including  March 2022 guidance which details specific strategies states may employ. CMS also articulates its expectations for states, for example by requiring that states must complete a post-PHE full renewal for each member before ending coverage. States, health plans, providers and advocates will want to assess this information and adapt it to reflect state-specific landscapes to avoid the loss of coverage by large numbers of eligible individuals.

What it Means for Medicaid Partners and Stakeholders

HMA is working with states and stakeholders to develop operational plans to minimize disruption and administrative burdens for Medicaid eligible individuals, state agencies, state-based Marketplaces, health plans and providers, as well as continue to advance alignment and integration opportunities. These plans include specific actions for states, health plans, providers, advocates, and other stakeholders tailored to reflect the landscape and resources on a state-by-state basis.

Our experience tells us that stakeholders will want to be preparing now to respond to the eligibility and enrollment needs of Medicaid enrollees and applicants. Strategies and timeframes for completing the required full renewal will vary by state. Stakeholders will want to:

  • Take steps now to prepare to assist Medicaid enrollees and support the full renewal process;
  • Monitor evolving state landscapes to learn how Medicaid agencies are planning for the resumption of eligibility and enrollment operations;
  • Work across stakeholder groups to provide specific assistance in implementing outreach and assistance plans;
  • Communicate with states about planning, outreach, and assistance initiatives.

Through our work with states and their partners, we identified major components and considerations guiding three major phases of work around renewals: planning, outreach to prepare for resumption of full renewals, and assistance once the renewal process begins. While the details will differ, the overarching issues are applicable in all states, regardless of the goals and parameters each state sets for completing work on the PHE-related backlog of renewals.

In the remainder of our post, we walk through the major phases and decision points for stakeholders and offer our perspectives on the longer-term trends we are engaged in helping stakeholders shape.

Phase 1: Planning – Build Common Understanding of State Timeframes and Processes. States will set parameters for the timeframes and processes guiding the full renewal processes. CMS is encouraging stakeholder participation in establishing these parameters. Stakeholders should be actively engaged with states in the development of these requirements. The following are several key parameters stakeholders should consider:

  • State agencies will identify the timeframe by which the state will begin and end processing PHE-related backlogged renewals and share these plans with stakeholders throughout the planning process. The March 2022 guidance strongly encourages states to initiate the full renewal process for no more than one-ninth (1/9) of their caseload in a month, but some states may set different goals.
  • State capacity and their preferred mechanisms to process full renewals and applications will differ. Stakeholders should understand how they can work with states on the most efficient processes for individuals to complete and submit renewal information and plan to assist Medicaid enrollees with these processes. They should also understand individual state renewal processes and requirements (how robust a state’s ex parte renewal process is, etc.) which may have changed from pre-pandemic processes.
  • States and their partners also will benefit from a shared understanding of how the state intends to prioritize or sequence full renewals for subgroups of enrollees. CMS’ March 2022 guidance identifies four risk-based approaches that states can use to prioritize this work:
    • population-based approach;
    • a time or age-based approach;  
    • a hybrid approach; or
    • a state-developed approach.

Partners and stakeholders can be most effective in their work if they understand the state’s preferred strategies and identify areas where they can support the state through outreach and assistance to enrollees.

  • States may also want to pursue alignment strategies that help them achieve an even distribution of work both during the 12-month unwinding period and in subsequent years. To support this, CMS identified several strategies that states can utilize during the 12-month unwinding period. The impact of the alignment efforts, however, would be realized beyond the unwinding period. For example, for beneficiaries also enrolled in the Supplemental Nutrition Assistance Program (SNAP), states may schedule their Medicaid renewals to coincide with the individual’s SNAP recertification, provided such recertification occurs within the 12-month unwinding period. States could also seek to align renewals for all members in a single household. Partners and stakeholders should endeavor to understand which alignment strategies states intend to pursue and approaches for supporting enrollees in these processes.

Phase 2: Outreach – Prepare for Resumption of Renewals. Stakeholder outreach and assistance can reduce the numbers of Medicaid eligible enrollees who lose coverage when it is time for their full renewal.  Medicaid enrollees will need clear and consistent information to support their renewal or transition to other insurance programs, when applicable. States may take the lead in developing messaging and identifying specific communication methods and tools for stakeholder use in:

  • Alerting Medicaid enrollees that the State needs their best contact information – addresses, phone numbers, email addresses, etc. by:
    • Undertaking outreach and messaging campaigns, including asking enrollees during every interaction about updated information;
    • Identifying a process to promptly submit new information to the State; and
    • Assisting individuals by completing the process to submit updated contact information to the State.
  • Assisting states in making Medicaid enrollees aware of the end of PHE, the start of the renewal process and how they can understand when they will have to act. CMS has emphasized the importance of health plan engagement in the full renewal process and clarified that health plans can communicate with their enrollees about transferring to the health plan’s Marketplace option, if the state allows.
    • Aligning with the state on communications strategies, processes, and tools like text messaging for use with Medicaid enrollees.

Phase 3: Assist in the Renewal Process Once It Begins. Stakeholders should be prepared with adequate, well-trained staff once the renewal process begins and regardless of which strategies states may employ. CMS strongly encourages states to use health plans, community-based organizations, and other stakeholders to assist enrollees throughout the renewal process. Stakeholders can:

  • Ramp up their capacity and training for community-based assistors.
  • Assist Medicaid eligible individuals with completion and timely submission of complete renewal forms and required documents to avoid a break in coverage.
  • Assist individuals who lost eligibility due to non-submission of renewal forms to promptly complete the reinstatement process.
  • Assist individuals found to be ineligible for Medicaid to promptly apply for Marketplace or other available coverage.

Longer Term Considerations

Some states may view the resumption of normal operations as an opportunity to evaluate existing Medicaid and CHIP eligibility policies and identify updates to simplify or expand policies and processes. For example, some states are newly considering 12-month coverage options, such as postpartum coverage and continuous eligibility. Where applicable, stakeholders could provide support for advancing these efforts by sharing projected or actual budgetary and programmatic analysis observed in other states.

In addition, this is also a tremendous opportunity for states to continue to further align the myriad of programs that many families are enrolled in to reduce churn and confusion. States may choose to schedule Medicaid renewals with SNAP recertifications and/or align work on renewals for all members of a household.

Separate from planning for resumption of Medicaid renewals and the resulting workload, HMA expects states and stakeholders to consider longer term opportunities related to Medicaid health plans that also participate in the Marketplace. For example, more states are now considering whether and how to incent health plan participation in both programs. In addition, there is greater federal attention on improving the hand-offs between Medicaid and Marketplace programs. Generally, these dynamics and state decisions could impact Medicaid and Marketplace enrollment well after the end of the PHE.

Finally, we expect federal policymakers to use the experiences with the PHE unwinding as well as responses to CMS’ “Request for Information: Access to Coverage and Care in Medicaid and CHIP,”[vi] to improve individual experience with Medicaid eligibility application processes in the future. This information and lessons learned will inform daily operations and potentially legislative and regulatory changes over the next several years.


[i] P.L. 116-127: https://www.congress.gov/116/plaws/publ127/PLAW-116publ127.pdf

[ii] Kaiser Family Foundation, “Analysis of Recent National Trends in Medicaid and CHIP Enrollment,” February 2022: https://www.kff.org/coronavirus-covid-19/issue-brief/analysis-of-recent-national-trends-in-medicaid-and-chip-enrollment/

[iii] Internal to HMA: Estimated Health Insurance Impact of COVID-19 Economic Downturn

[iv] Urban Institute, “What Will Happen to Unprecedented High Medicaid Enrollment after the Public Health Emergency?” September 2021: https://www.urban.org/sites/default/files/publication/104785/what-will-happen-to-unprecedented-high-medicaid-enrollment-after-the-public-health-emergency_0.pdf

[v] “Promoting Continuity of Coverage and Distributing Eligibility and Enrollment Workload in Medicaid,  the Children’s Health Insurance Program (CHIP), and Basic Health Program (BHP) Upon Conclusion of the COVID-19 Public Health Emergency”, March 3, 2022: SHO# 22-001; “Medicaid and Children’s Health Insurance Program COVID-19 Health Emergency Eligibility and Enrollment Pending Actions Resolution Planning Tool”, Updated March 3, 2022: Planning Tool; Overview of Strategic Approach to Engaging Managed Care Plans to Maximize Continuity of Coverage as States Resume Normal Eligibility and Enrollment Operation,” March 3, 2022: Overview; Strategies States and the U.S. Territories Can Adopt to Maintain Coverage of Eligible Individuals as They Return to Normal Operations, November 2021: https://www.medicaid.gov/sites/default/files/2021-11/strategies-for-covrg-of-indiv.pdf; SHO# 21-002 RE: Updated Guidance Related to Planning for the Resumption of Normal State Medicaid, Children’s Health Insurance Program (CHIP), and Basic Health Program (BHP) Operations Upon Conclusion of the COVID-19 Public Health Emergency, August 13, 2021: https://www.medicaid.gov/sites/default/files/2021-08/sho-21-002.pdf

[vi] Request for Information (RFI): Access to Coverage and Care in Medicaid & CHIP, February 17, 2022: https://www.medicaid.gov/

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Meet the HMA blog contributors

Jane Longo

Principal
Chicago, IL

Andrea Maresca

Principal, Federal Policy
Washington, DC